Key points

Introduction

For there are these three things that endure: Faith, Hope and Love, but the greatest of these is Love.

Burn treatment has been revolutionized in recent years, which has led to improved measurements of mortality and morbidity after injury and provided greater functionality and QOL for burn patients both in recovery and rehabilitation. In 1970, a 50% body surface burn carried only a 50% chance of survival, whereas today, a majority of patients survive burns that take up 75% or more of total body surface. Modern technology, in combination with improvements in surgical technique and wound coverage, is largely responsible for these advances. Recent improvements are just as dramatic, with progress in treatment and technology continuing to accelerate the recovery, resulting in a better outcome. Between 2002 and 2011, the average length of stay for burn patients decreased from approximately 11 days to 8 days. During the same 10-year period, mortality rate for men decreased from 4.8% to 3%, and for women, it declined from 5.4% to 3%.

These improvements are largely driven by changes and progress in surgical innovation and research. Innovation within reconstructive surgery continues to accelerate at a rapid and unprecedented pace; success in full facial transplants and promising stem cell discoveries could further revolutionize reconstructive techniques. Not surprisingly, today’s burn surgeons have many more tools in their arsenal than those of decades past. Traditional wound excision and skin grafting can now be supplemented with a variety of other techniques: dermal substitutes, laser surgery, and even newer, experimental approaches, such as the use of tissue engineering and the application of spray-on skin. As the fields of reconstructive and burn surgery continue to advance technologically, however, it is important to ensure that clinicians not lose sight of the multifaceted needs of patients, which extend far beyond their physical restoration.

Burn treatment is a long journey, often beginning with surgery but rarely ending with a wound excision or laser repair. Burn patients often experience medical complications and prolonged recovery as a result of damage to the skin. Patients also commonly experience psychosocial problems after burn injuries, given both the psychological and social stress involved as well as the physical symptoms and life changes brought on by their burns and treatments. Research has shown, however, that burn patients are generally able to achieve functional independence as well as a reasonable QOL. For instance, in a study of 38 severely burned patients in Australia, patients were able to return to driving at 38 weeks postinjury and to work at 51 weeks postinjury. Despite positive long-term outcomes, burn recovery is extensive, ranging from months to years of surgeries, rehabilitation, and follow-up. Helping patients achieve full recovery is thus a difficult and lengthy process that must account for a variety of patient needs, much of which depends on a patient’s psychosocial and spiritual healing.

Current knowledge: psychosocial factors and burn injuries

Burn injuries adversely affect psychological, social, behavioral, physical, occupational, and sexual functioning over time, presenting particular challenges given the high survival rate of burn victims today (>97%). Not surprisingly, a recent review of research on the mental and physical recovery of burn patients concluded that, “…the need for an emphasis on rehabilitation and recovery is paramount, with special focus on lessening the biopsychosocial impact of burn disfigurement, functional disability, mental disorders, and problems at school or work. A key goal is to teach patients and families strategies for successful rehabilitation, how to enhance resilience, how to reduce the stigma of burns, and help them cope effectively in society.” In addition, psychosocial factors are known to influence the rates at which surgical wounds heal, in both young healthy individuals and older adults. There is evidence that these factors may also influence the rate of wound healing, recovery of function, and QOL in burn patients.

Although those with serious burn injuries tend to adapt to their condition as time passes, there is considerable evidence that QOL remains diminished for months or years after the burn. Psychosocial factors, such as healthy family relationships, have been associated with greater QOL in pediatric burn patients. In adult patients, greater social support has been associated in cross-sectional analyses with higher QOL scores on mental health years after the burn injury. Likewise, greater community involvement has been associated with higher QOL at 6 months and 12 months after burn injury. Another study also examined the effects of “participation” on the QOL in 260 burn survivors from 12 months to 5 years postburn; however, their measure of participation combined social integration with occupational activity and physical mobility, making it impossible to determine the independent effects of social/community integration on QOL outcomes.

In contrast to the dearth of information on social and community factors, at least 5 studies in adults have prospectively examined the effects of psychological factors on burn patients’ QOL. The first study examined psychological health (depression, anxiety, and posttraumatic stress disorder [PTSD] symptoms) in 363 Australian burn patients at the time of hospital discharge and then again 12 months later, examining effects of psychological factors on physical functioning and QOL. Higher PTSD, anxiety, and depressive symptoms at hospital discharge predicted worse physical functioning and QOL a year later. In a second study, substance abuse at baseline (initial hospitalization) significantly predicted poor overall QOL (assessed using a visual analog scale) at 2 years to 7 years after burn injury in 67 Swedish patients. A third study involved an 18-month prospective study of 260 Dutch adult burn patients, finding that depressive symptoms and PTSD symptoms assessed 3 weeks after burn injury predicted health-related QOL trajectories of change over an 18-month follow-up. A fourth study examined 265 German burn patients and found that personality characteristics, PTSD symptoms, and depressive symptoms at 6 months postburn (baseline) predicted QOL indicators at 36 months postburn. Finally, a follow-up of 92 Finnish burn patients found that major depressive disorder soon after the burn predicted poorer QOL (physical, mental, and social) 6 months later.

Although there is a growing literature on the longitudinal effects of psychological factors at baseline on future QOL, there is limited information on how social factors or interpersonal relationships affect QOL. Most of the research available on psychosocial factors affecting patient’s functioning after burns, surprisingly, comes from countries outside the United States.

Introduction

For there are these three things that endure: Faith, Hope and Love, but the greatest of these is Love.

Burn treatment has been revolutionized in recent years, which has led to improved measurements of mortality and morbidity after injury and provided greater functionality and QOL for burn patients both in recovery and rehabilitation. In 1970, a 50% body surface burn carried only a 50% chance of survival, whereas today, a majority of patients survive burns that take up 75% or more of total body surface. Modern technology, in combination with improvements in surgical technique and wound coverage, is largely responsible for these advances. Recent improvements are just as dramatic, with progress in treatment and technology continuing to accelerate the recovery, resulting in a better outcome. Between 2002 and 2011, the average length of stay for burn patients decreased from approximately 11 days to 8 days. During the same 10-year period, mortality rate for men decreased from 4.8% to 3%, and for women, it declined from 5.4% to 3%.

These improvements are largely driven by changes and progress in surgical innovation and research. Innovation within reconstructive surgery continues to accelerate at a rapid and unprecedented pace; success in full facial transplants and promising stem cell discoveries could further revolutionize reconstructive techniques. Not surprisingly, today’s burn surgeons have many more tools in their arsenal than those of decades past. Traditional wound excision and skin grafting can now be supplemented with a variety of other techniques: dermal substitutes, laser surgery, and even newer, experimental approaches, such as the use of tissue engineering and the application of spray-on skin. As the fields of reconstructive and burn surgery continue to advance technologically, however, it is important to ensure that clinicians not lose sight of the multifaceted needs of patients, which extend far beyond their physical restoration.

Burn treatment is a long journey, often beginning with surgery but rarely ending with a wound excision or laser repair. Burn patients often experience medical complications and prolonged recovery as a result of damage to the skin. Patients also commonly experience psychosocial problems after burn injuries, given both the psychological and social stress involved as well as the physical symptoms and life changes brought on by their burns and treatments. Research has shown, however, that burn patients are generally able to achieve functional independence as well as a reasonable QOL. For instance, in a study of 38 severely burned patients in Australia, patients were able to return to driving at 38 weeks postinjury and to work at 51 weeks postinjury. Despite positive long-term outcomes, burn recovery is extensive, ranging from months to years of surgeries, rehabilitation, and follow-up. Helping patients achieve full recovery is thus a difficult and lengthy process that must account for a variety of patient needs, much of which depends on a patient’s psychosocial and spiritual healing.

Current knowledge: psychosocial factors and burn injuries

Burn injuries adversely affect psychological, social, behavioral, physical, occupational, and sexual functioning over time, presenting particular challenges given the high survival rate of burn victims today (>97%). Not surprisingly, a recent review of research on the mental and physical recovery of burn patients concluded that, “…the need for an emphasis on rehabilitation and recovery is paramount, with special focus on lessening the biopsychosocial impact of burn disfigurement, functional disability, mental disorders, and problems at school or work. A key goal is to teach patients and families strategies for successful rehabilitation, how to enhance resilience, how to reduce the stigma of burns, and help them cope effectively in society.” In addition, psychosocial factors are known to influence the rates at which surgical wounds heal, in both young healthy individuals and older adults. There is evidence that these factors may also influence the rate of wound healing, recovery of function, and QOL in burn patients.

Although those with serious burn injuries tend to adapt to their condition as time passes, there is considerable evidence that QOL remains diminished for months or years after the burn. Psychosocial factors, such as healthy family relationships, have been associated with greater QOL in pediatric burn patients. In adult patients, greater social support has been associated in cross-sectional analyses with higher QOL scores on mental health years after the burn injury. Likewise, greater community involvement has been associated with higher QOL at 6 months and 12 months after burn injury. Another study also examined the effects of “participation” on the QOL in 260 burn survivors from 12 months to 5 years postburn; however, their measure of participation combined social integration with occupational activity and physical mobility, making it impossible to determine the independent effects of social/community integration on QOL outcomes.

In contrast to the dearth of information on social and community factors, at least 5 studies in adults have prospectively examined the effects of psychological factors on burn patients’ QOL. The first study examined psychological health (depression, anxiety, and posttraumatic stress disorder [PTSD] symptoms) in 363 Australian burn patients at the time of hospital discharge and then again 12 months later, examining effects of psychological factors on physical functioning and QOL. Higher PTSD, anxiety, and depressive symptoms at hospital discharge predicted worse physical functioning and QOL a year later. In a second study, substance abuse at baseline (initial hospitalization) significantly predicted poor overall QOL (assessed using a visual analog scale) at 2 years to 7 years after burn injury in 67 Swedish patients. A third study involved an 18-month prospective study of 260 Dutch adult burn patients, finding that depressive symptoms and PTSD symptoms assessed 3 weeks after burn injury predicted health-related QOL trajectories of change over an 18-month follow-up. A fourth study examined 265 German burn patients and found that personality characteristics, PTSD symptoms, and depressive symptoms at 6 months postburn (baseline) predicted QOL indicators at 36 months postburn. Finally, a follow-up of 92 Finnish burn patients found that major depressive disorder soon after the burn predicted poorer QOL (physical, mental, and social) 6 months later.

Although there is a growing literature on the longitudinal effects of psychological factors at baseline on future QOL, there is limited information on how social factors or interpersonal relationships affect QOL. Most of the research available on psychosocial factors affecting patient’s functioning after burns, surprisingly, comes from countries outside the United States.

Current knowledge: spirituality and burn injuries

There is a significant and growing amount of literature suggesting that spiritual/religious resources (and struggles) can influence psychological, social, and behavioral outcomes and ultimately affect physical health, recovery, and overall survival. In particular, research in oncology and trauma surgery suggests that there is a positive relationship between spirituality/spiritual resources and outcomes of survivorship and QOL. In a study of 88 patients with traumatic brain injury, spiritual well-being was associated with better objective rehabilitation outcomes and served as a significant predictor for life satisfaction. Researchers have similarly demonstrated the positive association of spirituality with breast cancer survivorship in women and QOL for men with prostate cancer. Furthermore, epidemiologic research has indicated an overall positive effect of spirituality on survival, with 1 study finding spirituality/religiosity a more effective health intervention for mortality than consumption of fruits/vegetables and statin therapy.

There is almost no empirical research, however, on the effects that spirituality or spiritual resources have on burn recovery or on the spiritual consequences of burns (in terms of spiritual needs or struggles). To the authors’ knowledge, the first article to address the topic was published in 1988. The article, entitled “Adult Burn Patients: The Role of Religion in Recovery,” presented 2 case reports. Then, in 2006, an editorial titled “Adult Burn Patients: The Role of Religion in Recovery — Should We Be Doing More?” was published in the Journal of Burn Care & Research ; unfortunately, there has been little response to this question.

A recent comprehensive review identified only 4 articles that examined the spirituality of burn patients; 3 of the 4 were published from a single study from Brazil. Spirituality/religion as both a source of support and source of struggle or conflict were reported. In the first of these reports, a qualitative description of 8 burn survivors, results indicated that many relied on a spiritual or religious faith for support, although 1 participant said the experience shook his faith in God. The second report qualitatively addressed the “meanings of quality of life” for 19 burn survivors during rehabilitation and indicated that 2 of the patients said that their burn accident was a punishment imposed by God and the result of God’s will. The third qualitative report from this study (expanded now to 44 adult burn patients) indicated that 9 patients (20%) reported changes in their religious ties — 4 changing their religious affiliation to another denomination, 2 cutting all religious ties, and 3 reporting religious commitment had strengthened.

In the fourth article in this group, researchers examined the prevalence and impact of religious/spiritual coping in burn patients of 87 burn survivors and found that burn survivors frequently engaged in religious and spiritual forms of coping to manage the stress of their burn injury. Furthermore, the study reported that burn survivors who engaged in positive religious coping had better physical functioning, and that negative religious coping (spiritual struggles) was associated with several adverse outcomes, including poor sleep and worsening of PTSD symptoms 6 months and 12 months posthospitalization.

The authors’ comprehensive review identified an additional 6 studies that did mention the subject of spirituality. In the first study, researchers qualitatively examined sources of hope in 9 white male burn patients in a southwestern US facility, finding that only 2 of the 9 cited religion as a source of hope. In the second article, an editorial presented the results of a survey of 53 burn patients with greater than 10% total body surface area (TBSA) admitted to the acute care floor at University of Texas Southwestern Medical Center. Researchers found that more than two-thirds of participants (68%) said that addressing their religious and spiritual needs was important to their recovery and should be a part of their medical care. The next study surveyed 117 adult burn survivors from throughout the United States and other countries recruited at a 2007 conference for burn survivors (77% with >30% TBSA affected). When asked which factors were most important during burn recovery, 88% said family support, 35% indicated religion, and 17% said meditation.

Of the 2 most recent studies, 1 was a report on the development and validation of the 47-item Young Adult Burn Outcome Questionnaire, which includes 4 items on religion (amount of relief and support from religion, degree of religiosity, feeling distant from God, and agreement with statement “God dwells within you”). This questionnaire was administered to 153 burn patients and 112 subjects without burns. Participants were ages 18 to 30 at baseline (an average of 5 months from the burn injury) and were followed for 1 year to 2 years, examining trajectories of change in 15 functional domains. The religious domain changed little over the study period and was only slightly below and not significantly different from the trajectory followed by the nonburned control group. The effect of religiosity on the other trajectories of functional change was not reported.

The final study, conducted by the authors’ research group at University of North Carolina at Chapel Hill, was a retrospective review of all patients admitted to the North Carolina Jaycee Burn Center during 2011 (n = 1338). Demographic data, religious affiliation, number and type of pastoral care visits, length of stay, physician and facility charges, and information on mortality were collected. Results indicated that chaplains visited 314 patients (23.5% of all patients) with an average of 3.4 visits per patient. Patients visited by chaplains had a larger total TBSA burn, longer lengths of stay, higher charges, and greater mortality. Patients with a religious affiliation had slightly lower mortality than those without an affiliation (0.87% vs 3.2%), although the difference did not reach statistical significance. The authors concluded that plastic surgeons and burn providers might consider addressing the spiritual needs of burn patients.

In summary, 6 small qualitative studies, 3 cross-sectional studies, and 2 prospective quantitative studies have examined the role that spirituality/religion plays in the lives of burn patients. To the authors’ knowledge, these are the only studies of spirituality in persons with burn injuries, leaving a major gap in the literature in terms of empirical research — especially regarding the effects of spiritual/religious resources or struggles on physical, occupational, and sexual health outcomes acting through psychological, social, and behavioral pathways.